Another report by Parkland Memorial Hospital’s safety monitors brings into sharper focus why so many patient-safety failures have occurred at the Dallas institution in recent years: Its internal watchdog unit for policing patient care fell down on the job.

One example the report cites “involved the death of a patient following the administration of a narcotic drug by a nurse.” Parkland’s internal investigators with the Quality of Care Department “did not uncover the fact that the nurse administered drugs without a physician order.”

That flawed inquiry is symptomatic of a broader collapse of controls in rooting out widespread care breakdowns, from the lack of a strong data-driven tracking system to protocols for conducting inquiries, the report says. Interviews with staff are rarely conducted, and basic questions aren’t asked such as, what does this mean? Or what really happened, and why?

The 26-page report, an evaluation of the hospital’s quality assessment and performance improvement program, has been kept secret, along with other documents, by Parkland since late February. We obtained it through a Freedom of Information Act request to the Centers for Medicare & Medicaid Services, Parkland’s chief regulator. I’ve uploaded the report on this post’s continuation.

Among the findings in the quality assessment evaluation:

* “Adverse events are too often viewed as isolated incidents, rather than symptoms of a systemic problem … often there is little investigation of adverse events other than (patient) chart review, if that is performed.”
* The quality department has more than 60 employees and “is more than adequately resourced with personnel.”
* Its investigations frequently “are not conducted or completed in a timely manner.” The delays “result in fact gathering errors” and “mean that unsafe practices may be continuing.”
* Department employees sometimes delete safety reports if more than one caregiver writes up the same event. “Vital information has been lost.”

As we’ve told you this week, Parkland Memorial Hospital is continuing its not-your-business stance with the public about its strategy for fixing patient-care failures.

The publicly funded hospital is refusing to release the improvement plan created by federally installed safety monitors, which Parkland was forced to hire after flunking two government inspections last summer. Interim CEO, Dr. Thomas Royer, told employees that “external transparency to the public and the media will not help correct our deficiencies.”

Instead Parkland has offered only general information on reforms and avoided any discussion of the specific problems identified by the federally installed monitors. In fact, Parkland is still upset that we obtained the monitors’ initial investigative report, which detailed violations of 50 federal safety standards, and posted it online.

Luckily, we’ve also obtained some of the “safety updates” that Parkland sends its employees on new policies and procedures. We find them insightful and think you, as taxpayers and patients, will, too.

I’ve provided the full text of this week’s safety update on the continuation of this post. When we get others in the future, we’ll pass them along.